For a healthy start in life, children need smoke-free environments: Progress of the Generation Smoke-Free campaign in Belgium since its launch in 2018

1 Published by European Publishing on behalf of the European Network for Smoking and Tobacco Prevention (ENSP). © 2023 van Kalmthout D. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License. (https://creativecommons. org/licenses/by/4.0/) For a healthy start in life, children need smoke-free environments: Progress of the Generation Smoke-Free campaign in Belgium since its launch in 2018

Children have the right to grow up in a smoke-free environment The right to grow up smoke-free is defended by various articles of the UN Convention on the Rights of the Child (UNCRC), where the right to health (Article 24), the right to life, survival and development (Article 6) are key. In Article 6, the UNCRC goes even further than the right to life and survival as set out in other human rights treaties, because it includes the child's right to development.
The bodies of children and youngsters are still developing, making them among the most vulnerable members of the population. At least 250 of the 4000 chemicals in tobacco smoke are known to be very harmful to health, and more than 70 of these substances are known to cause cancer 5,6 . Children exposed to passive smoke have a reduced lung function and an increased risk of respiratory infections, asthma, behavioral problems and learning difficulties. Smoking teenagers have less healthy airways and more cardiovascular diseases 7 . Adolescence is also a time when teenagers experiment, including with tobacco, with a high risk of addiction, and an industry keen to find 'replacement smokers'.
Children and youngsters have the right to grow up healthy and to become healthy adults, without harmful substances adversely affecting their development. Generation Smoke-Free therefore puts children's rights at the forefront of its campaigns to ensure that present and future generations can grow up smoke-free.
No more cigarette butts Cigarette filters are an environmental hazard and are among the 10 most common plastics in the world's oceans. Every year, an estimated 4.5 trillion cigarette filters are dumped into the environment 8 .
The main component of cigarette butts is plastic (cellulose acetate). The filter was introduced to reduce the health impact of cigarette smoking. In retrospect, this turned out to be mainly a marketing trick, because research has shown that the filter actually causes smoke to be inhaled more deeply and that fibers from the cellulose acetate may also end up in the lungs. As we now know, the claims that filtered cigarettes were 'healthier' were fraudulent 8 . The only thing filters may have done is to make smoking easier and less harsh, increasing both the risk of addiction for smokers and the overall burden of the nonbiodegradable and toxic cellulose acetate filters in our environment 9 . Moreover, cigarette butts contain the same toxic chemicals found in cigarettes, such as arsenic and nicotine, threaten our aquatic ecosystems, and are toxic when ingested by children or wildlife 10 .
Smoke-free environments have the additional advantage of reducing the number of cigarette butts that end up on the ground. From all the available information currently at our disposal, we know that a minimum of 951 smoke-free playgrounds and 207 smoke-free sports grounds have been established since 2018. This is an impressive result, knowing that in 2018 we started with 6 pioneer municipalities who made the commitment to smoke-free areas at the time. Some municipalities even went a step further and made other environments smoke-free as well, such as the area around all public entrances to municipal buildings, the area around school gates, etc.

Results
In Wallonia, almost 30 municipalities have started to implement smoke-free environments within the framework of Generation Smoke-Free, so far mainly in the province of Hainaut. out to measure the level of public support for making areas frequented by many children smoke-free.

Some recommendations
The smoking survey by the Foundation Against Cancer indicated that 89% of the Belgian population believe that children have the right to grow up smoke-free, and that they support the Generation Smoke-Free principle 11 . Eight out of ten Belgians believe that places frequented by large numbers of children (such as children's farms, playgrounds, sports facilities, and zoos), as well as hospital campuses, should be smoke-free 12 . Non-smokers and ex-smokers are, according to the survey, more positive about smoke-free environments, and indeed a majority of smokers also back smoking bans in most environments, with the exception of open terraces, train platforms and festivals.
Create a network of partners to work together towards a first smoke-free generation Generation Smoke-Free is a broad movement supported by over 150 local authorities, civil society organizations, sports federations, medical associations, companies, etc. All these partners have signed a Charter endorsing the movement's mission, vision, goals and approach, and committing to work together towards a first smoke-free generation in Belgium.
Moreover, over 160 municipalities and organizations have obtained the Generation Smoke-Free label by making environments frequented by children smoke-free and by supporting smokers who want to quit. The label can only be obtained if a number of conditions are met: clear signs should indicate that the location is smoke-free, smoking areas are permitted but limited in number and out of sight of children, all stakeholders have been informed that the location is smoke-free and about the new rules, and ashtrays are removed (except in the smoking area, if one exists).
This growing societal support has a positive impact on the political effort to achieve a first smokefree generation in Belgium by 2037. The more municipalities and organizations support our mission and create smoke-free children's environments, the greater the support for the political measures that the Alliance for a Smoke-Free Society advocates towards politicians, such as raising taxes, reducing the number of points of sale, or introducing a displayban.

Focus on environments frequented by children
Making outdoor environments frequented by children smoke-free is an important measure to achieve a smoke-free generation. After all, research shows that children will be less inclined to start smoking if it is no longer seen as normal and attractive behaviour 13,14 . The vast majority of smokers (90%) started smoking before the age of 18 years. Experimental behavior is common among adolescents and young people become addicted to nicotine very quickly -much faster than adults. This is because the adolescent brain is much more sensitive to the rewarding effects of nicotine compared to the adult brain. Rewarding stimuli play an important role in the continuation of smoking and the development of nicotine dependence 15 .
The campaign has therefore decided to focus on achieving smoke-free areas in the most significant outdoor spaces where children are present, including care areas, sports grounds, playgrounds, school environments, petting zoos, and youth movements.
Protecting children's health through the creation of smoke-free environments is central in our communication. A telling example is our annual campaign in the context of the International Children's Rights Day campaign on 20 November. Here, the right to a smoke-free environment is claimed by children for children.

An inclusive approach to smokers
Smokers play a central role in our campaign. After all, making environments smoke-free cannot be done without their help. They are the ones who are being asked to set a good example and to ensure that smoking takes place out of sight of children. In general, smokers are cooperative if the rationale behind the campaign, i.e. protecting children's health, is explained, because they, too, do not want their children to smoke later on.
More smoke-free environments, including outdoors, make it essential to assist smokers even more in their efforts to stop smoking. The good news is that more than two in three smokers want to quit smoking. But quitting smoking can be difficult. According to the smoking survey of the Foundation Against Cancer, 56% of smokers relapse within 3 months 16 . On average, it takes 5 attempts to stop before they achieve definitive success.
A smoke-free environment invites people who smoke to think about their smoking addiction and therefore provides a very appropriate place to inform smokers how they can get rid of their addiction. Moreover, smoke-free environments also help people who are quitting not to be tempted to start smoking again.
In the framework of our campaign, we have developed specific signposting for any smoking areas located on the premises, out of sight of children, referring to a high quality quitline (Tabakstop), where smokers are given information and are referred, if desired, to professional counselling to help them stop smoking.

Smoke-free environments: a decisive bottom-up measure
Making outdoor environments smoke-free through positive labelling, encouraging smokers to quit or, if not possible, to smoke out of children's sight, and teaching children a different norm about smoking, is an important contribution to achieving the first smoke-free generation in Belgium. And this is urgently needed. It is incomprehensible that a consumer product, which kills more than half of its users, is available on every street corner, when it violates human rights, lures countless children worldwide every day into nicotine addiction, causes a tremendous environmental impact, and vastly drives up the costs to be borne by the whole of society.
Smoke-free environments are not the only measure to stop this misery, and their effects will become apparent in the long-term. However, they will ensure that today's children will stop viewing smoking as a pleasurable experience. They will initiate societal debate on smoking, in sports clubs, schools, hospitals, town councils, zoos, amusement parks and so on. They will make smokers who enter a smoke-free environment reflect on their addiction and perhaps consider seeking professional help to stop. Finally, they will ensure that cigarette butts do not end up as waste in the environment.
The daily achievements of people and communities working together to create smokefree environments will ensure that the ambition of a smoke-free generation gains a foothold in the whole of society. Such bottom-up support is essential to denormalize smoking and to ensure that children in the future see cigarettes as a curiosity of the past.